Q&A: Patient misidentification

Patient misidentification is an underreported problem that still plagues healthcare. Despite electronic records, bar codes, and checklists, many patients end up getting the wrong procedure, medicine, care, or diagnosis. 

Brad Truax, MD, is board-certified in both neurology and internal medicine, and has more than 20 years of experience in medical administration and patient safety. He spoke with BOAQ about patient mix-ups: why they still happen and what can be done to stop them. 

This Q&A has been lightly edited for clarity. 

Q: Why do facilities still struggle with patient ID mix-ups? It seems like it would be an easy thing to solve.

Truax: Sounds like it ought to be easy, but there’s two main problems: the name problem and the IT problem. They’re the biggest reasons we haven’t been able to solve this.

The [statistics on] people with similar names is pretty astonishing. There’s one study where they looked at patients in a ward over a three-month period; they found that on at least a third of the days there were at least two people with the same last name. In the [neonatal ICU], it’s even more frequent. 

For a number of years now through Joint Commission, we’ve gone to two-factor identification. And in most places, that’s the first and last name plus the date of birth (DOB). But it’s still possible to have [patients with] both.

A friend of mine has a daughter whose first and last names are identical to somebody else in the hospital system, and they have the same DOB. In that circumstance, the hospital had to notify both people, “Hey, you might be at risk for misidentification. You need to always be sure that they’ve got the correct person.”

The issue is, we can’t ask the patient, “What’s your name and DOB?” because that’s a process that’s prone to error. The patient might not understand, or can’t hear well, or have a language problem or other problems that may have them nod yes when you say, “Is your name James Brown?”

It needs to be an active process, [asking] “What is your name?” and have the patient tell us their name. Same with DOB. Sometimes people will get complacent and skip that process. 

The second problem is IT. When I did my first electronic medical record (EMR) implementation 10 years ago, I predicted that we’d see more wrong-patient events happen, for several reasons. 

First, the identifiers weren’t always present on all the screens. When you go through a patient record, it might be present on the first record you go to, but if you scroll through screens, it wasn’t listed. Now most of the medical record vendors have improved on that, so in general we can see the name on all the screens. 

There are other issues, like the juxtaposition error. That’s whenever you have a drop-down menu, it’s very easy to click on the wrong name. 

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